Background

Clinicians at NorthShore had been monitoring, and working on, their rates of central-line-associated
bloodstream infections (CLABSIs) since 2007. By 2009, the rates were pretty good (1.45
per 1,000 line-days), but the health system's infection experts were still looking
for further improvement.

“Most programs such as mine have vendors contacting us on a regular basis saying,
‘Hey, you really need to look at this [device].’ The problem is that
it doesn't mean it actually works,” said Marc-Oliver Wright, MS, corporate
director of infection control. But when a manufacturer contacted him about trying
out a new catheter hub disinfection cap with a sponge saturated in 70% alcohol, he
was interested.

“The actual design of a catheter hub with its corkscrew physique makes it hard
to clean effectively,” he said. “You have to stop what you're doing
[in the process of accessing the central line] and instead of giving the patient the
drug, you have to stand there, and scrub, scrub, scrub for 15 seconds.”

To assess the effectiveness of this potential solution, Mr. Wright convinced the device
manufacturer to let the health system conduct a three-phase trial of the caps.

How it works

The NorthShore team started their project by assessing current contamination rates
in central lines to establish a baseline rate for comparison. After several months
of monitoring, the new catheter caps, containing alcohol-soaked sponges, were threaded
on to all central lines that were not actively in use. When a clinician wanted to
use the line, he would remove and discard the cap. After the infusion was complete,
a new cap was screwed on.

Each hospital had an education program about how to use the device itself, and continued
to do quantitative blood cultures of the fluid in the line. Then, after about six
months, the new caps were removed from one of the hospitals. This represented phase
3 of the effectiveness trial, intended to establish definitively whether the caps,
not some confounder, were responsible for any improvements in contamination or infection
rates. “We knew that once we took the device away and said to go back to scrubbing
the hubs, if it was the device, we'd see an increase in infections,” said Mr.
Wright.

Results

NorthShore saw a drop in contamination and CLABSIs after implementation and a rise
when the caps were taken away, according to results in the January American Journal of Infection Control. “Bacteria in the intraluminal space had dropped by about half and the organism
density of samples that were positive was cut by 75%. We saw that the infection rate
itself was cut by 52%. All of those findings were statistically significant,”
said Mr. Wright.

A NorthShore cost-effectiveness analysis indicated that for about $60,000 per year
in caps, the hospitals could make room for almost 13 more admissions per year, thanks
to fewer extended stays for CLABSIs.

The intervention was also popular with clinicians. “You don't have to do anything
before you access the line, except take it off and throw it away, which takes a half-second,”
said Mr. Wright.

Challenges

Because the device was so easy to use, forgetfulness and lack of education were the
main challenges to consistent implementation. “We had to do a lot of compliance
checks….Periodically, throughout the day, you might have someone come in there
and draw a lab instead of contacting the [vascular access] team and forget to put
a new cap on,” Mr. Wright said. “When we fell short, we did have to
do some reinforcement, some re-education.”

Next steps and final thoughts

After seeing the results of the study, the health system's corporate infection control
committee was convinced to make the caps part of the standard of care. “We
had two of our hospitals go for more than a year without a single line infection,”
said Mr. Wright. “Our line infection rate has stayed in the [range of] 0.5%
of all patients with lines.”

It's possible that the caps don't prevent contamination or infections any better than
thorough scrubbing would, said Mr. Wright. But if an intervention like this can make
infection prevention substantially more convenient for clinicians, it can improve
compliance enough to change outcomes.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.